AMY POSTS

DEAR ERI COMMUNITY: I have a question that I have struggled with the answer for a while now. I understand how our services as school based therapist are supposed to be educationally relevant. We get referrals of children of all types for services. What do my fellow PTs do with the child whose gross motor skills are behind that of his peers? I always try to make things functional for access to the school environment. Do you ever write goals/objectives for children who can’t hop on one leg or balance on one leg, skip, jump consecutively etc? In the past I have, but we are having to revamp how our goals are written to support the present level of performance in the educational environment. The only standardized test I have available has been the Peabody and really I don’t see how that test is educationally relevant except for the stairs,walk, run part. So if you get low scores, the parent still feels you should see the child even if they can maneuver in the school. We have ordered the School Function Assessment recently but have not used it yet. Seems it does not even look at gross motor skills. Do you include higher level gross motor skills goals if it is a deficit for the child? And how do you write said goals on the IEP if you do so? I just want some pointers so I know if I am doing the right thing. I typically include goals for gait, stairs, and balance/coordination GMS, but it seems best practice is steering away from this. Advice please

I have included the School Function Assessment as part of my evaluations for the past fee years. It paints a better picture of what is needed for accessing the school environment and provides much more relevant information for school related goals.

I like the Test of Gross Motor Development – 2nd Edition (TGMD-2) as it addresses the skills needed within the PE class, which is part of the curriculum. I will write goals that relate to PE curriculum that may include hopping on one foot, etc for my higher-level kids who need more than APE to help them gain the necessary skills.

Hi Amy, Your are correct that school-based motor goals are moving away from specific skills & should be more functional. Every state and every district has different guidelines for ‘qualifying scores’ & writing goals for related services. Make sure you always check that. Next, the best reference for me has been Providing Physical Therapy Services Under Parts B & C of IDEA; edited by Irene R McEwen,PT,PhD,FAPTA. I’ve used this for the 17+ yrs that I’ve done school based and early intervention. It was updated in 2009.
I’ve used the School Functional Assessment(SFA) & the Bruininks-Oseretsky Test of Motor Proficiency(BOT™-2) as well as the Peabody. The SFA is a good activity & participation assessment. Have you considered looking at the district’s curriculum and standards for PE? This ties services directly into educational relevance. Your goals would then read something like this: Johnny will participate in PE class with his peers at an age-appropriate level by ….kicking a ball, doing an obstacle course, running a relay, shooting baskets, etc… then how you will measure that. Access goes beyond opening the front door and walking to the classroom. Look at access in the lunch room – carrying a tray, sitting at the table, getting up from the table & emptying tray. Or field trips – getting on and off a bus, uneven terrain, strength and endurance for it. Finally, access to the playground – can the child play independently and safely on age-appropriated playground equipment? Others may have better info or options for you. This is what has worked for me in the settings I serve. Good luck!

Unfortunately I work in a rural area without many options for outpatient therapy for kids and do not have many parents who would regularly take them even if it was available. Sometimes I feel I am all the child’s got to address these issues

I do find a lot value in what Theresa wrote… That being said, in order for me, as a school-based PT, to recommend services, I have to be certain that the underlying deficits require my unique skill-set as a licensed physical therapist to improve. If the phys ed teacher can be instructed or knows how to help the student progress or learn, then “teaching” that skill-set is not unique to me as a physical-therapist. Physical education teachers are more than qualified to help a student improve fitness, strength, balance and coordination in a vast majority of cases. As such, I do not feel I can legally pull this student from his/her LRE to treat. Otherwise, I feel we’d be treating every low-tone or “under” coordinated student who is classified. Perhaps, some of the teachers need a bit of guidance and some of these students can be serviced through a consultative model. In addition, students are not typically graded on their actual performance in phys ed class but, instead, on effort and participation. So, if a student has sufficient skills to attempt participation and reap the benefits of phys ed — social and physical — then I will not address specific phys ed skills in my goals.

Comment from Mickie:
The age/grade level of the student should be looked at. If the student is of an age that they still could be found eligible to receive special education services under the category of developmentally delayed, then you can address the gross motor skills you indicted are an issue. However, the goals and objectives would need to be written in a way that the gross motor skill develpoment would be needed so that the student could access his/her educational placement. Also services could be done on a direct basis or via consult ( example with PE teacher) I use the school functional assessment because it gives you a good indication as to specific functional gross motor skills needed in the educational environment as opposed to other tests which may indicate develpmental delays -however once past the age of being found eligible under the category of DD they need another category of eligibility to receive related services ( OT,PT and or Speech) to begin with. If a student no longer can or is found eligible to receive services under the DD category you would need to look at: if they cannot hop or stand on one foot, skip, etc, then what educational outcome are you looking at? if the answer is only access to the PE curriculum, find out if there is an adapted PE specialist in your district to address accommodations/modification needed in PE class.
In the school setting you are not soley looking at gross motor deficits, but how those deficits are impacting ( or mot) a student’s ability to access thier educational placement. Also look at accomodations: seating, time between classes, adapted PE if their is an adapted PE specialist in your area, Or equipment, activity modifications in PE class….

I typically include one legged balance, unilateral hop, jumping and marching objectives with my preschool and kindergarten kids bc they do these activities in circle time and they deal with participation. We don’t have APE in our county. Students really aren’t graded on PE either. It’s more of a participation grade

This seems like the perfect type of kiddo to refer to an outpatient clinic for these community/participation goals. I work in this setting and see a lot of these types of kids. I like the Peabody, the BOT and the TGMD, as mentioned by others. It’s nice to be able to instruct parents directly, because so much of the success with the higher level gross motor skills depends on home carryover and frequent practice. We have not had trouble getting insurance to approve, though it tends to be a short-term benefit if it is just for gross motor delay (or muscle weakness, low tone, etc.). The only time I have trouble getting coverage is when school PT is also involved and has goals for these types of activities.

Unfortunately I work in a rural area without many options for outpatient therapy for kids and do not have many parents who would regularly take them even if it was available. Sometimes I feel I am all the child’s got to address these issues

Comment from Kristine
I would strongly suggest that you look at the SFA (school function assessment) which looks at all skills that are needed to function in a school environment. It really helped me to restructure my thinking of what is educationally relevant to include a much wider range of skills.
Good Luck!

I agree that the School Function Assessment is invaluable especially when looking at progress during reevaluations, it can demonstrate even incremental progress especially with lower functioning students. My district DOES NOT have adaptive PE so a lot of my goals/objectives address specific participation in general ed PE classes

I try to look beyond test scores to why the child can’t “hop on one foot” or “perform 5 jumping jacks”. I use mainly the BOT 2 and SPA (Sensory Performance Analysis) for school aged children. My goals (which must be measurable) are usually drawn from these tools such as “perform 5 jumping jacks moving arms and legs in synchronization” or “crawl along a 15′ “s” curve using all four extremities equally, utilizing a reciprocal crawling pattern”. During meetings I correlate the test findings to school curriculum. For example the child with decreased strength and endurance will tire quickly and not be able to attend throughout a full day of classroom instruction. The child with below average balance scores may have visual perceptual issues that will effect reading. Below average bilateral integration may indicate immature integration of one side of the brain with the other resulting in difficulties in reading comprehension or in abstract math processes. I also include this information in the narrative parts of the IEP or 504 plans. As long as the test scores are significantly below average, CSE chairs have been receptive to this approach and teachers hear information that makes sense to what they see day to day and become strong supporters of services.

I certainly understand the reasoning as to the ways we can help children improve academic performance via our interventions. I struggle with the goal writing for these things. Unless I am writing a goal directly pertaining to access or movement in the educational environment , it’s hard. How do you show on an IEP that your goals are educationally relevant when the are for for higher level gms? I guess I need examples…

I use the SFA at times, but find it to be a bit unwieldy when done correctly (requires a group to assess the child). I also use the Battelle and the GMFM. However, some kiddos are able to access their school environment fully, but perhaps with an awkward gait pattern or with paraprofessional support, and they no longer need PT in school. This raises the issue of when and how to D/C PT in the schools. If I use a standardized test in these cases, the score often comes out low, and argues against a D/C. In all cases, I try to stay in touch with a child’s teachers to find out what problems they see as the child goes the school day, attending to lessons, sitting in a chair, floor transfers as part of circle time, moving around the building, stairs, playground, bus, lunch room, etc. My first cut is to write goals based on the gross motor aspect of these identified difficulties, as confirmed by my evaluation. I also write measurable goals involving hopping, skipping, jumping, or other general school-appropriate gross motor tasks. For success criteria, I sometimes will include a narrative such as, “With minimal hands-on assistance of trained classroom staff, Johnny will,,,”, thereby taking myself out of the picture as the determinant of success and replacing PT with the staff who spends all year with the child. I find that the more I include the special ed teacher or case manager in my goal-setting process, the better I serve the child by having the gross motor goals fit in with the IEP as a whole. I hope you find this helpful. Thanks for the question!

What state are you from? The Department of Education for California put out Guidelines for OT and PT in CA Public Schools.http://www.bot.ca.gov/forms_pubs/otpot_guidelines_2012.pdf
There are several appendixes that are very helpful in terms of what PTs focus on and how that gives a child equal access to the educational curriculum alongside his peers – straight out of IDEA 2004. It even gives sample goals to write that involve using stairs, jumping, ball skills etc. Whether you are from CA or not, it is a helpful resource to rework goals to make them more “educational”.

I use the Peabody and like it because it gives me age equivalents for the Early Start program and percentile scores which work for the school districts. It gives me what skills they need to be working on to have equal access alongside peers.

I’m in rural TN but will definitely check that out. The problem with Peabody is the age cut off along with it just looking at strict GM versus their mobility as a whole within the school. Our kids are not graded in PE other than participation

I use the Peabody and the BOT-2 to assess the students with gross motor delays at the elementary school level. My gross motor goals are written ‘Will improve gross motor skills in order to facilitate participate in PE and recess activities with peers’. Most teachers and administrators in our schools are well aware of the impact bilateral skills, motor planning, and core strength have on the student’s ability in the classroom. Once the student reaches middle school, the SFA is used, and discussions regarding adaptation versus skill building is emphasized. We do not have adaptive PE at the elementary level, but do have it from middle school on. We also use the SFA for our younger students with significant motor impairments. But every school system does interpret the laws differently and have their own guidelines!!

Debbie, That goal sounds great but we have to be very specific in regards to our goals being measurable in my district. How do you include performance measures or data collection in that particular example? That is something i struggle with. Do you you specify certain skills?

Amy – I also work in a rural area with limited APE and outpt services. While you may want to provide all you can to a student, you do have to stay within IDEA guidelines. To expand on my first post with goal example: Johnny will participate in PE class with his peers at an age-appropriate level…” you can measure in lots of ways – how often (every day, 7/10 days; 7/10 sessions, or 7/10 throws/jumps/kicks; 7/10 play structures, 70% of class time); distance (walking or kicking/throwing a ball); you can measure time (how long it takes to walk down the hall); you can measure by amount of help (independent, supervision, contact guard, min, mod , max, total); how often help it given(1-2 physical prompts, 1-2 verbal cues, no cues); or the quality of the skill. And you need an end date: one year, 6 months, etc. Just remember these are the student’s goals, not the therapist’s goals, to increase independence in his/her educational environment and make sure you are clear on your district’s measurement requirements. Do get the IDEA book from APTA – about $70. It’s a great resource. I’ve presented info from it to school staff to support related services. I hope this helps!

I am also posting to be able to follow this thread. I live in a very rural area in northern NH. I work at a hospital that covers OP/IP/SNF/home health/and schools. I cover all areas including working 1-day/wk in an elementary school and can use all the guidance I can get! A big thank you to the more experienced pediatric therapists for the guidance, it is certainly the hardest setting in my opinion!

Hi,
I prefer the SFA as it focuses on function and participation in specific school activities vs. developmental levels of gross motor isolated skills. It is only for grades K-6, but I use some test items for grades 7-12 without official scoring (just percentages)and the disclaimer that it is informational use only or as a baseline.
The SFA helps parents see their child’s level of independence in school-related activities, even if they “walk funny” or step non-reciprocally on stairs. (I don’t care how they get up/down if they keep up with peers, are safe, and can go where they want to go.)
Also, I’ve used the Pediatric Balance Scale, Timed Up and Go, Time Up/Down stairs, and some other standardized simple tests, which you can find in the School-Based Special Interest Group of the Pediatric Section of the APTA. (They have a TON of info available to non-members, and I highly recommend exploring their treasure trove, as well as the resources others have mentioned above. Laurie Ray at University of North Carolina has a ton of free info on her site as well. (GO to one of the pediatric APTA courses if you can, such as SOPAC or Innovations in SBPT. Totally worth it full-price.)
I do have a question about the SFA. I know on Part 3 you can pick and choose what areas to test (I only do Travel, Maintaining/Changing Positions, and Recreational Movement), but do you think Parts 1 and 2 are optional as well? Parts 1 and 2 have some “PT-type” areas, but they also go into behavior, fine motor, socialization, most of which are not specific to my area of intervention. Sometimes I do it with the OT, but they don’t always choose that test. I find the Parts 1 and 2 Scoring Guide vague and inconsistent in several places, and often teachers and aides have a hard time filling out their parts. Does anyone skip that and only do Part 3? The instruction manual doesn’t specify that all parts need to be done. Thanks!

Wondering if anyone is still on this thread. I work at an approved private school in PA with pretty handicapped kiddos, although we do have some walkers. They are pushing to integrate, but I’m having trouble with goals that are going to address needs but not be “PT” specific. I can say they will transition sit to stand to access the table, but criteria are difficult too as I’m in there once per week generally, and the teachers don’t want to collect my data. (and their staff may give increased assistance and count it as success vs what I do, which will skew the data).